Michael Shernoff.

Gay psychotherapist Michael Shernoff was infected with HIV during the darkest days of the epidemic and lost many close friends to AIDS. Yet even then Shernoff was being visited almost daily by gay male patients who refused to use condoms. Shernoffs first book, Without Condoms, draws on a large number of case studies and over 1,500 responses to an Internet survey to take on the hornet's nest of psychological factors that compel many gay men to take serious risks in the bedroom. He spoke by phone from his office in Manhattan after a full day of meetings with patients.

You treat gay men who engage in very risky sexual behavior, yet you advocate an approach that is free of what you call "sex-negativity." Is this a place you arrived at in writing the book? I would call it an evolution. I started discussing unsafe sexual behavior with patients in the earliest days of the epidemic. It's important for me to meet patients where they are at. Good therapy provides curative emotional experiences. I don't need to act like a nonapproving parent. If I shake my finger at [patients] and try to tell them what to do, they feel judged and infantilized. A harm-reduction approach can help the individual make certain choices that reduce the risk to himself and to the broader community should he choose not to use condoms during sex.

Many people believe that barebacking is confined to young gay men who didn't witness the worst of the epidemic. Is this true? Absolutely not. All our current research says that the vast majority of gay men are not using a condom every time they have sex. This is not a single group of "bad gays." This is everybody, at least some of the time, regardless of ethnicity, educational background, and age.

You write that a "sex-negative" approach is detrimental to any discussion of risky sexual behavior. Can you define "sex-negative" and explain some of the problems posed by this approach? Basically, a sex-negative approach is antipleasure. It preaches abstinence only, and it doesn't recognize that for some men, sex without a condom fulfills a variety of deep important needs, some of which are actually spiritual. Then there are men who have taken on the identity of the barebacker because it is their way of remaining a sexual outlaw. To encourage these men to increase their condom use, we need to speak to them in a way that addresses their realities. These men are not seeking to spread the virus or become infected, and they can be open to exploring a harm-reduction approach [if it is] addressed to them without judgment.

What are some of these emotional needs that drive gay men to abandon condoms?

Connection. Intimacy. Desire. Pleasure. For some people, sex without condoms is an expression of love and trust. For others, it's the belief that nasty sex is better sex. One of the greatest joys of sexuality is abandon, and AIDS throws a bucket of cold water on that. The fact is, some people may prioritize pleasure and intensity over their own longevity. The point is, these reasons are not all pathological. But they are difficult for gay men to discuss because many of us have vestiges of an internalized homophobia, which turns into a kind of internalized erotophobia, a fear of sex and pleasure, which is a part and parcel of the puritan streak in this country, where sex is used to sell everything except sex education. It's possible to have public-health approaches to preventing both unwanted pregnancies and sexually transmitted diseases that are sex-positive.

To find more from this conversation, click on LINKS at www.advocate.com.